Fentanyl

The safety of transdermal fentanyl (TF) in comparison with slow-release oral morphine (SROM) in moderate-severe pain was assessed. A systematic review of the literature was performed to identify all randomized trials comparing TF and SROM in moderate-severe pain. Overall safety was the primary end point. Trials enrolling both cancer and non-cancer patients were included in the analysis. Heterogeneity was assessed using the Mantel-Haenszel test; a random effects model was used for the pooled analysis. Cumulative and distinctive analyses for cancer and non-cancer pain were performed whenever the outcome was reported in at least two trials. Five trials met the inclusion criteria. A significant advantage of TF was documented for constipation, laxative use, and urinary retention. TF was preferred by cancer and non-cancer patients. A difference in favour of SROM was documented for nausea, diarrhea, and sweating in cancer and non-cancer patients. No differences were observed for the other ...

Although the majority of potentially preventable fatalities among U.S. combat forces serving in Afghanistan and Iraq have died from hemorrhagic shock, the majority of U.S. medics carry morphine autoinjectors for prehospital battlefield analgesia. Morphine given intramuscularly has a delayed onset of action and, like all opioids, may worsen hemorrhagic shock. Additionally, on a recent assessment of prehospital care in Afghanistan, combat medical personnel noted that Tactical Combat Casualty Care (TCCC) battlefield analgesia recommendations need to be simplified--there are too many options and not enough clear guidance on which medication to use in specific situations. They also reported that ketamine is presently being used as a battlefield analgesic by some medics in theater with good results. This report proposes that battlefield analgesia be achieved using one or more of three options: (1) the meloxicam and Tylenol in the TCCC Combat Pill Pack for casualties with relatively minor pain who are still able to function as effective combatants; (2) oral transmucosal fentanyl citrate (OTFC) for casualties who have moderate to severe pain, but who are not in hemorrhagic shock or respiratory distress and are not at significant risk for developing either condition; or (3) ketamine for casualties who have moderate to severe pain but who are in hemorrhagic shock or respiratory distress or are at significant risk for developing either condition. Ketamine may also be used to increase analgesic effect for casualties who have previously been given opioids (morphine or fentanyl.).

Amplitude changes of event-related sensory potentials (SEP's) present objective measurements for the evaluation of pain perception in man. Alfentanil, an opioid with dominant binding to the mu-receptor was given in graded doses (5-, 10- micrograms/kg) to volunteers. Nalbuphine, an opioid with reported kappa-agonist activity, was given in graded doses (100-, 500-, 1000- micrograms/kg) to another group i.v. Both groups were also exposed to progressively increased electrical stimulations (mA) in order to determine tolerance threshold before and after drug administration. In the alfentanil group (n = 5) there was a dose- related decrease of the amplitude of the early N20-peak. The late N100-peak was not, however, affected. This correlated closely (r = 0.87) with a naloxone-reversible increase of tolerance to electrical current. In the nalbuphine group (n = 15), there was a dose-related, naloxone non-reversible reduction of amplitude of the late N100-peak which showed a good correlat...

OBJECTIVE:
We quantified transdermal fentanyl prescribing in elderly nursing home residents without prior opioid use or persistent pain, and the association of individual and facility traits with opioid-naïve prescribing.

DESIGN:
Cross-sectional study.

SETTING:
Linked Minimum Data Set (MDS) assessments; Online Survey, Certification and Reporting (OSCAR) records; and Medicare Part D claims.

PARTICIPANTS:
From a cross-section of all long-stay US nursing home residents in 2008 with an MDS assessment and Medicare Part D enrollment, we identified individuals (≥65 years old) who initiated transdermal fentanyl, excluding those with Alzheimer disease, severe cognitive impairment, cancer, or receipt of hospice care.

MEASUREMENTS:
We used Medicare Part D to select beneficiaries initiating transdermal fentanyl in 2008 and determined whether they were "opioid-naïve," defined as no opioid dispensing during the previous 60 days. We obtained resident and facility characteristics from MDS and OSCAR records and defined persistent pain as moderate-to-severe, daily pain on consecutive MDS assessments at least 90 days apart. We estimated associations of patient and facility attributes and opioid-naïve fentanyl initiation using multilevel mixed effects logistic regression modeling.

RESULTS:
Among 17,052 residents initiating transdermal fentanyl, 6190 (36.3%) were opioid-naïve and 15,659 (91.8%) did not have persistent pain. In the regression analysis with adjustments, residents who were older (ages ≥95 odds ratio [OR] 1.69, 95% confidence interval [CI] 1.46-1.95) or more cognitively impaired (moderate-to-severe cognitive impairment, OR 1.99, 95% CI 1.73-2.29) were more likely to initiate transdermal fentanyl without prior opioid use.

CONCLUSION:
Most nursing home residents initiating transdermal fentanyl did not have persistent pain and many were opioid-naïve. Changes in prescribing practices may be necessary to ensure Food and Drug Administration warnings are followed, particularly for vulnerable subgroups, such as the cognitively impaired.

For thousands of years, opioids have been used to treat pain, and they continue to be one of the most commonly prescribed medications for pain. It is estimated that 90% of patients presenting to pain centers and receiving treatment in such facilities are on opioids. Opioids can be considered broad-spectrum analgesics that act at multiple points along the pain pathway. Unfortunately, opioids also have the potential for great harm, with multiple side effects and potential complications, some of which are lethal. They are also uniquely addictive, which can lead to misuse and diversion. We reviewed the relevant English literature and did thorough manual searches of the bibliographies of known primary and review articles. We utilized pain relief as the primary outcome measure. Other outcome measures were functional improvement, improvement of psychological status, improvement in work status, and evidence of addiction. Short-term use and improvement was defined as less than 6 months and l...

A series of experiments were performed to better understand the mechanism of the In-loop [11C]CH3I-methylation. The timing of [11C]CH3I delivery is critical for the high yield of radiolabeling since in-loop radioactivity trapping is reversible. Trapped radioactivity escapes faster from a Tefzel loop compared to a PEEK- or stainless steel loop. Up to 50% of delivered radioactivity may be concentrated at the loop origin (representing 8.1% of the total loop volume). A five-fold reduction of the reaction solvent volume and/or precursor amount may lead to a decrease of the product radiochemical yield either by lowering the in-loop radioactivity trapping or by diminishing conversion of [11C]CH3I into the product.